Provider Demographics
NPI:1902982267
Name:LUCKIE DRUG LLC
Entity Type:Organization
Organization Name:LUCKIE DRUG LLC
Other - Org Name:LUCKIE DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:LUCKIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-822-3789
Mailing Address - Street 1:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:OKEENE
Mailing Address - State:OK
Mailing Address - Zip Code:73763-0549
Mailing Address - Country:US
Mailing Address - Phone:580-822-3789
Mailing Address - Fax:580-822-3136
Practice Address - Street 1:116 N MAIN ST
Practice Address - Street 2:
Practice Address - City:OKEENE
Practice Address - State:OK
Practice Address - Zip Code:73763-9446
Practice Address - Country:US
Practice Address - Phone:580-822-3789
Practice Address - Fax:580-822-3136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-30
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4955193336C0003X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100246010AMedicaid
2134003OtherPK